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Pediatrician Bedside Manner May be Key to Improving Vaccination Rates
R. J. Crayton   May 31, 2014   Ethical Technology  

 The recent spate of disease outbreaks, such as the measles and mumps in Ohio, has led to more calls for improving public health through better vaccination. While vaccines are readily available in the United States, many parents choose not to vaccinate their children.  

Why? Well, the answer involves a little study that made big news nearly two decades ago. A 1998 study by Andrew Wakefield found a link between Measles-Mumps-Rubella vaccinations and autism. While the study was later discredited, the findings continue to be touted by some, who feel that while the link isn’t proven, something about the vaccines causes autism. Jenny McCarthy and Holly Robinson Peete have been big proponents of not vaccinating, due to their perceived links between the vaccinations and autism.

Both have a child who was diagnosed with autism after receiving a vaccination.

Because enough parents are opting out of vaccination, diseases which had been under control are having regional outbreaks, such as whooping cough and measles. These disease are costly healthwise, and sometimes deadly to children, so a very real public health threat.

A Washington Post blogger said these anti-vaccine parents are endangering lives. Researcher Brendan Nyhan, in a piece for the New York Times, said his recent study finds that parents who are anti-vaccination become more entrenched the more information they are provided that contradicts their views. However, his research indicates doctors, if trained well, may be able to persuade some of these reluctant parents.

As a parent and a participant of a mother’s group whose read a lot about vaccination issues, I tend to think Nyhan is correct: pediatricians are key. Only pediatricians often make parents more entrenched, rather than persuade them of the benefits of vaccination.

Pediatricians should be at the forefront of the issue, as parents come to them for medical advice and treatment. However, pediatricians, seeing the overall public health costs of vaccines, often treat parents who have questions about vaccination with hostility and threats. Dr. Bob Sears, author of the Vaccine Book, notes on his website: “Most doctors around here kick patients out of their practice for not vaccinating, or for asking too many questions.”

Now that would be like a person going to a doctor, learning he suffered an affliction and when he asked questions about the proposed treatment, the doctor calling the patient foolish for having such questions and saying in no uncertain terms that the have to leave the practice if he didn’t want to follow the doctor’s advice.

Seems an extreme reaction. Yet this is the reaction that a fair number of doctors have when it comes to vaccines. It’s not helping the situation. In Nyland’s research on changing vaccination attitudes of parents, he found that most education efforts corrected misperceptions parents had about links between autism and vaccination, but didn’t increase the likelihood that parents would vaccinate. (The research was published in the journal Pediatrics; an early version is online here, as the Pediatrics article is only available to subscribers.) Given this, Nyland contends that doctors are the best source to help change doctors’ attitudes.

In the NYT piece, he writes, “A more promising approach would require parents to consult with their healthcare provider.... Parents name their children’s doctor as their most trusted source of vaccine information. That trust might allow doctors to do what evidence alone cannot: persuade parents to protect their children as well as yours and mine.”

I would agree. However, telling a patient they’re not welcome if they don’t vaccinate isn’t persuasion. It’s simply making parents doctor shop, which doesn’t increase childhood vaccination rates. Persuasion is about listening to concerns and addressing them. It’s about offering facts without offering a hostile adamancy that seems rehearsed and fake. Saying, “vaccines don’t cause autism” with all the vigor that Bill Clinton used when he said he did not have sex with that woman, produces the same believability results.

The primary concern parents are expressing when they hesitate or refuse to vaccinate is safety of their child. So, doctors should focus on that when talking to parents about vaccination. Explaining both the safety angle of vaccination, the dangers of the disease, and discussing the issue with the same respect they would any other health-related matter (high blood pressure, diabetes, smoking cessation), would be helpful.

Nadia Qureshi, MD, a pediatric infectious disease specialist at Loyola University Health System, notes that many parents view vaccinations as optional because they don’t see the diseases as harmful or untreatable. Nowadays, we vaccinate against diseases like the Chicken Pox, which many people (myself included) contracted as a child. Because of this parents associate all vaccines with comfort, rather than safety (even though some of these diseases can be deadly). In parents’ cost-benefit analysis, they worry about exposing their child to some unknown harm (autism, vaccine side effects) when they perceive the disease they’re vaccinating against as a known quantity that they simply take their child to doctor and it gets treated.

“Many people think it’s just a virus and my child will get better,” Qureshi said. “Unfortunately, it’s not as simple as that. This virus can make your child miserable and can lead to serious complications and even death.”

​Doctors who refuse to take time with their parents and issue ultimatums drive parents away when they should be doing the opposite, because the public health stakes are so high.

“Vaccine rates were so good in this country that many physicians have seen it in books or photos, but no live cases,” Qureshi said. “This can make it difficult to diagnose and people can be walking around with the contagious virus not even knowing it.”

Doctors have to remember that for patients, it’s about more than just the numbers, so citing study results doesn’t assuage people’s concerns. Most parents see themselves as the protectors of their child, not society at large, particularly people who choose not vaccinate. So, persuading them is going to have to focus on that, not big picture items (stopping mass outbreaks) that doctors and public health officials think of.

It’s important for doctors to figure out ways to address hesitant parents that deals with their concerns and moves them to vaccinate, otherwise we’ll see more outbreaks like in Ohio.

R.J. Crayton is a novelist living in the Washington, DC, metropolitan area. More information is available on her website.



COMMENTS

This article ignores a critical point.  If your pediatric practice is located in an area experiencing a vaccine-preventable disease outbreak (such as pertussis or measles), there is a much higher risk of those diseases spreading in one’s waiting room if your practice has a lot of unvaccinated children. How fair is it to the parents of a newborn that their child be exposed to whooping cough from an unvaccinated 10-year-old who having coughing fits in the same waiting room. And should the parent of a child with a heart transplant have to worry her child is being exposed to measles by that unvaccinated child with the high fever and rash who is also in the waiting room. The answer to this is: NO.  My practice has been in this scenario for pertussis. The families who would not vaccinate would not vaccinate even if it was the end of the world. Nothing I could say or do would change their minds. So those families were asked to leave the practice. Quite simply, and not really discussed here is that vaccine rates have fallen enough in the US that herd immunity is being lost. I’m doing talking to people who won’t vaccinate because Jenny McCarthy or Oprah or Dr. Oz or Dr Sears told them not to. They can go elsewhere for the medical care of their unvaccinated children. One thing you also may not realize is that it was one of Dr. Bob Sears’s own unvaccinated patients that started the 2008 San Diego County measles outbreak when that child was taken to another physician’s waiting room and infected almost everyone unvaccinated in that waiting room. Quoting Dr. Sears was not the wisest thing to do here.

That’s just it. I don’t think I miss a critical point in that waiting rooms are where disease is spread. Perhaps I wasn’t clear in my point. I’m not saying a pediatrician can’t, at some point, say a parent who isn’t vaccinating is not in line with his/her pediatric practice and suggest they find another pediatrician. I am, however, saying that having that be the first thing out of a pediatrician’s mouth is unsettling to parents who haven’t made up their minds and could be swayed to vaccinate with some reasonable discussion and addressing of their concerns.

I agree with you that there are people who aren’t going to vaccinate no matter what you say to them. But, I don’t think you treat every patient who expresses concerns over what they’ve read in the news or heard on television the way you treat the person who comes in and says, “I’m not ever vaccinating my child and there is nothing you can do to change my mind.” Unfortunately, doctors are lumping these people together, perhaps because of bad experiences with the latter, and it’s hurting chances of converting the former.

Herd immunity is being lost, and that’s a bad thing. I think doctors focusing on the general community (which is what they’re dealing with), rather than the specific parent and child (what the parent is dealing with) is unpersuasive to many parents. This is so for two reasons. First, it’s very abstract to discuss the dangers to the “community” (which is often nebulous, at best, in people’s mind). Explaining how the loss of herd immunity specifically effects their child (making him/her more at risk if exposed to measles) is a better approach. Many of the nonvaccinators say, “well, most other people are getting the shot, so my kid is unlikely to get the disease anyway.” Dispelling that notion can help.  The second reason the community argument isn’t that convincing is because you’re inherently saying to the parent, “Stop being a selfish prig and get on board with what everyone else is doing.” That kind of sentiment doesn’t go over well with anyone, and causes people to want to dig in their heels. Our mothers told us not to jump off a cliff because everyone else was doing it and we’re inherently wary of arguments that hinge on everyone else doing it. We need to be shown a specific reason why it’s a good idea for us in particular to jump off a cliff, to continue the analogy (though vaccination is much healthier than cliff jumping).

The complete vaccine naysayers (like Jenny McCarthy) will never be convinced, but when you treat all people with questions or doubts like they’re naysayers, it turns more of those people into naysayers and hurts the conversion rate at a time when what we most need is more parents stepping up to get their children vaccinated.

As to Dr. Sears’ patient starting the outbreak, I’m not sure how that is relevant to the quote I chose. Are you suggesting that if Dr. Sears had turned them away (kicked them out of his practice) they would have vaccinated their children? But you contend there is nothing doctors can say to these people. So, if Dr. Sears had kicked them out of his practice, they still wouldn’t have vaccinated their children, and we would have had the same result. That patient would have walked into some doctor’s office (unless you’re arguing that people who don’t vaccinate their children just don’t go to doctors when their children are sick; and I don’t know of any basis for that position) and infected other children with measles as he waited for a doctor. I also don’t find anything particularly in error about Sears’ quote that most doctors kick patients out for refusing to vaccinate. You yourself said you do just that, so I think the Dr. Sears quote was both accurate and appropriate.

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